Many professionals and media sources have proclaimed that suicide is a 100% preventable problem. Although I completely disagree with that message—and find it terribly offensive—I also believe that we should do what we can to prevent suicide.

Recently I was asked to write a journal article summarizing the conditions or dimensions that commonly contribute to suicide. To give you a flavor of these dimensions, below I’ve included brief descriptions of each one. However, I also want to emphasize that suicidologists and suicide researchers agree that death by suicide is nearly always unpredictable. Suicide is unpredictable despite the fact that, afterwards, many people and professionals will feel as though they should have “seen the signs” and done something more to prevent the death.

Knowing the following eight dimensions is useful when they’re used to enhance your compassion and capacity to collaborate with individual clients and persons. They’re not designed to be used as suicide risk factors or predictors.

Here are the eight dimensions.

Unbearable Psychological/Emotional Distress (Shneidman’s Psychache)

Shneidman (1985) originally identified “psychache” as the central psychological force leading to suicide. He defined psychache as negative emotions and psychological pain, referring to it as “the dark heart of suicide; no psychache, no suicide” (p. 200). In more modern patient-oriented language, psychache is aptly described as unbearable emotional distress. Unbearable distress can involve many factors, or center around one main trauma, loss, or other psychologically activating experiences; it may be accompanied by distinct cognitive, emotional, or physical symptoms.

Problem-Solving Impairment (Shneidman’s Mental Constriction)

Depression or low mood is commonly associated with problem-solving impairments. Originally, Shneidman called these impairments mental constriction, and defined them as “a pathological narrowing of the mind’s focus . . . which takes the form of seeing only two choices: either something painfully unsatisfactory or cessation” (1984, pp. 320–321). Researchers have reported support for Shneidman’s original ideas about mental constriction (Ghahramanlou-Holloway et al., 2012; Lau, Haigh, Christensen, Segal, & Taube-Schiff, 2012).

Agitation or Arousal (Shneidman’s Perturbation)

Agitation or arousal is consistently associated with death by suicide (Ribeiro, Silva, & Joiner, 2014). Shneidman (1985) originally used the term perturbation to refer to internal agitation that moves patients toward suicidal acts. When combined with high psychological distress and impaired problem-solving, agitation or arousal seems to push patients toward acting on suicide as a solution to their distress. Trauma, insomnia, drug use (including starting on a trial of serotonin-reuptake inhibitors), and many other factors can elevate agitation (Healy, 2009).

Thwarted Belongingness and Perceived Burdensomeness

Joiner (2005) developed an interpersonal theory of suicide. Part of his theory includes thwarted belongingness and perceived burdensomeness as contextual interpersonal factors linked to suicide. Thwarted belongingness involves unmet wishes for social connection. Perceived burdensomeness occurs when patients see themselves as flawed in ways that make them a burden to others.

Hopelessness

Hopelessness is a broad cognitive variable related to problem-solving impairment and linked to elevated suicide risk (Hagan, Podlogar, Chu, & Joiner, 2015; Strosahl, Chiles, & Linehan, 1992). Hopelessness is the belief that whatever distressing life conditions might be present will never improve. In many cases, patients hold a hopeless view—even when a rational justification for hope exists.

Suicide Desensitization

Joiner (2005) and Klonsky and May (2015) have described how fear of death or aversion to physical pain is a natural suicide deterrent present in most individuals. However, at least two situations or patterns can desensitize patients to suicide and reduce natural suicide deterrence. First, some patients may be predisposed to high pain tolerance. This predisposition is likely biogenetic, as in blood-injury phobias (Klonsky & May, 2015). Second, patients may acquire, through desensitization, a numbness that reduces natural fears of pain and suicide. Chronic pain, self-mutilation, and other experiences can be desensitizing.

Suicide Plan or Intent

In and of itself, suicide ideation is a poor predictor of suicide. Nevertheless, ideation is an important marker to explore with patients; exploring ideation can lead to asking directly about whether patients have a suicide plan. Suicide plans may or may not be associated with suicide intent. Some patients will keep a potential suicide plan on reserve, just in case their psychological pain grows unbearable. These patients do not intend to die by suicide, but they want the option and sometimes they have thought through the method(s) they might employ.

Lethal Means

Access to a lethal means is a situational dimension that substantially contributes to suicide risk. Firearms are far and away the most lethal suicide method. Specifically, Swanson, Bonnie, and Appelbaum (2015) reported that firearms result in an 84% case fatality rate. Although firearms can quickly become a politicized issue in the U.S., researchers have repeatedly found that access to firearms greatly magnifies suicide risk (Anestis & Houtsma, 2017).

Spring is coming to the Northern Hemisphere. Along with spring, there will also be a bump in death by suicide. To help prepare counselors and clinicians to talk directly with clients about suicide, I’m posting an excerpt from the Clinical Interviewing text. The purpose is to help everyone be more comfortable talking about suicidal thoughts and feelings because the more comfortable we are, the more likely clients are to openly share their suicidal thoughts and feelings and that gives us a chance to engage them as a collaborative helper.

Because of this, you may decide to systematically ask every client about suicide ideation during initial clinical interviews. This is a conservative approach and guarantees you won’t face a situation where you should have asked about suicide, but didn’t. Alternatively, you may decide to weave questions about suicide ideation into clinical interviews as appropriate. At least initially, for developing professionals, we recommend using the systematic approach. However, we recognize that this can se0em rote. From our perspective, it is better to learn to ask artfully by doing it over and over than to fail to ask and regret it.

The nonverbal nature of communication has direct implications for how and when you ask about suicide ideation, depressive symptoms, previous attempts, and other emotionally laden issues. For example, it’s possible to ask: “Have you ever thought about suicide?” while nonverbally communicating to the client: “Please, please say no!” Therefore, before you decide how you’ll ask about suicide ideation, you need the right attitude about asking the question.

Individuals who have suicidal thoughts can be extremely sensitive to social judgment. They may have avoided sharing suicidal thoughts out of fear of being judged as “insane” or some other stigma. They’re likely monitoring you closely and gauging whether you’re someone to trust with this deeply intimate information. To pass this unspoken test of trust, it’s important to endorse, and directly or indirectly communicate the following beliefs:

Suicide ideation is normal and natural and counseling is a good place for clients to share those thoughts.

I can be of better help to clients if they tell me their emotional pain, distress, and suicidal thoughts.

I want my clients to share their suicidal thoughts.

If my clients share their suicidal thoughts and plans, I can handle it!

If you don’t embrace these beliefs, clients experiencing suicide ideation may choose to be less open.

Asking Directly about Suicide Ideation

Asking about suicide ideation may feel awkward. Learning to ask difficult questions in a deliberate, compassionate, professional, and calm manner requires practice. It also may help to know that, in a study by Hahn and Marks (1996), 97% of previously suicidal clients were either receptive or neutral about discussing suicide with their therapists during intake sessions. It also may help to know that you’re about to learn the three most effective approaches to asking about suicide that exist on this planet.

Use a normalizing frame. Most modern prevention and intervention programs recommend directly asking clients something like, “Have you been thinking about suicide recently?” This is an adequate approach if you’re in a situation with someone you know well and from whom you can expect an honest response.

A more nuanced approach is to ask about suicide along with a normalizing or universalizing statement about suicide ideation. Here’s the classic example:

Well, I asked this question since almost all people at one time or another during their lives have thought about suicide. There is nothing abnormal about the thought. In fact it is very normal when one feels so down in the dumps. The thought itself is not harmful. (Wollersheim, 1974, p. 223)

Three more examples of using a normalizing frame follow:

I’ve read that up to 50% of teenagers have thought about suicide. Is that true for you?

Sometimes when people are down or feeling miserable, they think about suicide and reject the idea or they think about suicide as a solution. Have you had either of these thoughts about suicide?

I have a practice of asking everyone I meet with about suicide and so I’m going to ask you: Have you had thoughts about death or suicide?

A common fear is that asking about suicide will put suicidal ideas in clients’ heads. There’s no evidence to support this (Jobes, 2006). More likely, your invitation to share suicidal thoughts will reassure clients that you’re comfortable with the subject, in control of the situation, and capable of dealing with the problem.

Use gentle assumption. Based on over two decades of clinical experience with suicide assessment Shawn Shea (2002/ 2004/2015) recommends using a framing strategy referred to as gentle assumption. To use gentle assumption, the interviewer presumes that certain illegal or embarrassing behaviors are already occurring in the client’s life, and gently structures questions accordingly. For example, instead of asking “Have you been thinking about suicide?” you would ask:

When was the last time when you had thoughts about suicide?

Gentle assumption can make it easier for clients to disclose suicide ideation.

Use mood ratings with a suicidal floor. It can be helpful to ask about suicide in the context of a mood assessment (as in a mental status examination). Scaling questions such as those that follow can be used to empathically assess mood levels.

Is it okay if I ask some questions about your mood? (This is an invitation for collaboration; clients can say “no,” but rarely do.)

Please rate your mood right now, using a zero to 10 scale. Zero is the worst mood possible. In fact, zero would mean you’re totally depressed and so you’re just going to kill yourself. At the top, 10 is your best possible mood. A 10 would mean you’re as happy as you could possibly be. Maybe you would be dancing or singing or doing whatever you do when you’re extremely happy. Using that zero to 10 scale, what rating would you give your mood right now? (Each end of the scale must be anchored for mutual understanding.)

What’s happening now that makes you give your mood that rating? (This links the mood rating to the external situation.)

What was happening back then to make you feel so down? (This links the lowest rating to the external situation and may lead to discussing previous attempts.)

For you, what would be a normal mood rating on a normal day? (Clients define their normal.)

Now tell me, what’s the best mood rating you think you’ve ever had? (The process ends with a positive mood rating.)

What was happening that helped you have such a high mood rating? (The positive rating is linked to an external situation.)

The preceding protocol assumes clients are minimally cooperative. More advanced interviewing procedures can be added when clients are resistant (see Chapter 12). The process facilitates a deeper understanding of life events linked to negative moods and suicide ideation. This can lead to formal counseling or psychotherapy, as well as safety planning.

Responding to Suicide Ideation

Let’s say you broach the question and your client openly discloses the presence of suicide ideation. What next?

First, remember that hearing about your client’s suicide ideation is good news. It reflects trust. Also remember that depressive and suicidal symptoms are part of a normal response to distress. Validate and normalize:

Given the stress you’re experiencing, it’s not unusual for you to sometimes think about suicide. It sounds like things have been really hard lately.

This validation is important because many suicidal individuals feel socially disconnected, emotionally invalidated, and as if they’re a social burden (Joiner, 2005). Your empathic reflection may be more or less specific, depending on how much detailed information your client has given you.

As you continue the assessment, collaboratively explore the frequency, triggers, duration, and intensity of your client’s suicidal thoughts.

Frequency: How often do you find yourself thinking about suicide?

Triggers: What seems to trigger your suicidal thoughts? What gets them started?

Duration: How long do these thoughts stay with you once they start?

Intensity: How intense are your thoughts about suicide? Do they gently pop into your head or do they have lots of power and sort of smack you down?

As you explore the suicide ideation, strive to emanate calmness, and curiosity, rather than judgment. Instead of thinking, “We need to get rid of these thoughts,” engage in collaborative and empathic exploration.

Some clients will deny suicidal thoughts. If this happens, and it feels genuine, acknowledge and accept the denial, while noting that you were just using your standard practice.

Okay. Thanks. Asking about suicidal thoughts is just something I think is important to do with everyone.

On the other hand, if the denial seems forced, or is combined with depressive symptoms or other risk factors, you’ll still want to use acknowledgement and acceptance, but then find a way to return to the topic later in the session.

Way back in 1990, a university book salesman came by my faculty office at the University of Portland. He was trying to sell me some textbooks. When I balked at what he was offering, he asked, “Do you have any textbook ideas of your own?” I said something like, “Sure” or “As a matter of fact, I do.” He handed me his card and a paper copy of Allyn & Bacon’s proposal guidelines.

Not having ever written a book, I never thought they’d accept my proposal.

They did. But after three years, A & B dropped our text.

Lucky for us.

Two years later, Rita and I decided to try to resurrect our Clinical Interviewing text. We polished up a proposal, sent it out to three excellent publishers, and immediately got contract offers from W. W. Norton, Guilford, and John Wiley & Sons.

We went with Wiley.

Here we are 18 years later in the 6th edition. It’s been fun and a ton of work. Over the past five years we’ve started recording video clips and interviewing demonstrations to go along with the text. For the 6th edition, we got some pretty fantastic reviews from some pretty fancy (and fantastic) people. Here they are:

“I’m a huge admirer of the authors’ excellent work. This book reflects their considerable clinical experience and provides great content, engaging writing, and enduring wisdom.”—John C. Norcross, Ph.D., ABPP, Distinguished Professor of Psychology, University of Scranton

“The most recent edition of Clinical Interviewing is simply outstanding. It not only provides a complete skeletal outline of the interview process in sequential fashion, but fleshes out numerous suggestions, examples, and guidelines in conducting successful and therapeutic interviews. Well-grounded in the theory, research and practice of clinical relationships, John and Rita Sommers-Flanagan bring to life for readers the real clinical challenges confronting beginning mental health trainees and professionals. Not only do the authors provide a clear and conceptual description of the interview process from beginning to end, but they identify important areas of required mastery (suicide assessment, mental status exams, diagnosis and treatment electronic interviewing, and work with special populations). Especially impressive is the authors’ ability to integrate cultural competence and cultural humility in the interview process. Few texts on interview skills cover so thoroughly the need to attend to cultural dimensions of work with diverse clients. This is an awesome book written in an engaging and interesting manner. I plan to use this text in my own course on advanced professional issues. Kudos to the authors for producing such a valuable text.”—Derald Wing Sue, Ph.D., Professor of Psychology and Education, Teachers College, Columbia University

“This 6th edition of Clinical Interviewing is everything we’ve come to expect from the Sommers-Flanagan team, and more! Readers will find all the essential information needed to conduct a clinical interview, presented in a clear, straightforward, and engaging style. The infusion of multicultural sensitivity and humility prepares the budding clinician not only for contemporary practice, but well into the future. Notable strengths of the book are its careful attention to ethical practice and counselor self-care. The case studies obviously are grounded in the authors’ extensive experience and bring to life the complexities of clinical interviewing. This is a ‘must-have’ resource that belongs on the bookshelf of every mental health counselor trainee and practitioner.”—Barbara Herlihy, PhD. NCC, LPC-S, University Research Professor, Counselor Education Program, University of New Orleans

This short case example from the forthcoming 6th edition of Clinical Interviewing is a small tribute to all the great supervisors I had over the years.

Case Example 7.2:

Intermittent Unconditional Positive Regard and Parallel Process

Abby is a 26-year-old graduate student. She identifies as a White Heterosexual female. After an initial clinical interview with Jorge, a 35-year-old who identifies as a male heterosexual Latino, she meets with her supervisor. During the meeting she expresses frustration about her judgmental feelings toward Jorge. She tells her supervisor that Jorge sees everyone as against him. He’s extremely angry at his ex-wife and he’s returning to college following his divorce and believes his poor grades are due to racial discrimination. Abby tells her supervisor that she just doesn’t get Jorge. She thinks she should refer him instead of having a second session.

Abby’s supervisor listens empathically and is accepting of Abby’s concerns and frustrations. The supervisor shares a brief story of a case where she had difficulty experiencing positive regard toward a client who had a disability. Then, she asks Abby to put herself in Jorge’s shoes and imagine what it would be like to return to college as a 35-year-old Latino man. She has Abby imagine what might be “under” Jorge’s palpable anger toward his ex-wife. The supervisor also tells Abby, “When you have a client who views everyone as against him, it’s all the more important for you to make an authentic effort to be with him.” At the end of supervision Abby agrees to meet with Jorge for a second session and to try to explore and understand his perspectives on a deeper level. During their next supervision session, Abby reports great progress at experiencing intermittent unconditional positive regard for Jorge and is enthused about working with him in the future.

One way to enhance your ability to experience unconditional positive regard is to have a supervisor who accepts your frustrations and intermittent judgmental-ness. If the issues that arise in therapy are similar (or parallel) to the issues that arise in supervision, it’s referred to as parallel process (Searles, 1955). This is one reason why when you get a dose of unconditional positive regard in supervision, it may help you pass it on to your client.

Not surprisingly, violence has been on my mind lately. And so when I reached the Violence Risk Assessment section of the Clinical Interviewing text revision, I decided to cut and paste it here. It doesn’t immediately answer the question of whether mental health professionals can predict violence and so if you’re impatient and prefer to stop reading now, the answer to that question is, more or less, “No.”

Assessment and Prediction of Violence and Dangerousness

During an assessment interview, John had the following exchange with a 16-year-old client.

John: I hear you’ve been pretty mad at your shop teacher.

Client: I totally hate Mr. Smith. He’s a jerk. He puts us down just to make us feel bad. He deserves to be punished.

John: You sound a little pissed off at him.

Client: We get along fine some days.

John: What do you mean when you say he “deserves to be punished”?

Client: I believe in revenge. Really, I feel sorry for him. But if I kill him, I’ll be doing him a favor. It would end his miserable life and stop him from making other people feel like shit.

John: So you’ve thought about killing him?

Client: I’ve thought about walking up behind him and slitting his throat.

John: How often have you thought about that?

Client: Just about every day. Whenever he talks shit in class.

John: And exactly what images go through your mind?

Client: I just slip up behind him while he’s talking with Cassie [fellow student] and then slit his throat with a welding rod. Then I see blood gushing out of his neck and Cassie starts screaming. But the world will be a better place without his sorry ass tormenting everybody.

John: Then what happens?

Client: Then I guess they’ll just take me away, but things will be better.

John: Where will they take you?

Client: To jail. But I’ll get sympathy because everyone knows what a dick he is.

During an initial interview or ongoing therapy, clients may describe aggressive thoughts and images. Some clients, as in the preceding example, will be concise about their thoughts, feelings, and images. Others will be less clear. Still others will be evasive and will avoid telling you anything about violent thoughts or intentions.

Assessing for violence potential is similar to assessing for suicide potential; it’s a stressful responsibility and predicting violence is extremely difficult. However, similar to suicide assessment, we still have a legal and ethical responsibility to conduct violence or dangerousness assessments that meet professional standards.

Over the years, there have been arguments about how to most accurately predict violence (Hilton, Harris, & Rice, 2006). Essentially, there are three perspectives.

2. Some clinicians believe that because actuarial variables are dimensional and interactive with individual and situational characteristics, prediction based on the clinician’s experience and intuition is most accurate (Cooke, 2012).

3. Others take a moderate position, believing that combining actuarial and clinical approaches is best (Campbell, French, & Gendreau, 2009).

Researchers have consistently reported that actuarial approaches to violence prediction are more accurate than clinical judgment (Monahan, 2013). However, actuarial violence prediction is not without its flaws (Szmukler, 2012; Tardiff & Hughes, 2011).

Narrowing in on Particular Violent Behaviors

Researchers who investigate actuarial assessment protocols have reported that different violent behaviors are associated with unique predictor variables. Below, we provide three examples of violence predictors for three different specific violent behaviors or populations. The goal is to sensitize you to different violent behavior patterns.

Fire-setting. Fire-setting is a particular dangerous behavior that may or may not be associated with interpersonal violence. Nonetheless, depending on your work setting and the clinical population you serve, you may find yourself in a situation in which you need to decide whether to warn a family or potential victim about possible fire-setting behavior.

Mackay and colleagues (2006) reported on specific behaviors included on a fire-setting prediction assessment. They identified the following variables—in decreasing order—as predictive of fire setting:

A lower offender’s aggression score. (Interestingly, offenders with higher aggression scores were more likely to be violent, but less likely to set fires.)

We focus first on fire setting here because fire-setting predictors illustrate a general violence-prediction principle. Past violence is a reasonably good predictor of future violence only with regard to specific past and future violence. For example, future fire-setting potential is best predicted by past fire-setting behavior. Similarly, future physical aggression is best predicted by past physical aggression. But a history of physical aggression is not a good predictor of fire setting.

Homicide Among Young Men. Loeber and associates (2005) conducted a large-scale landmark study of homicide among young men living in Pittsburgh. This study is notable because it was both prospective and comprehensive; the authors tracked 63 risk factor (predictor) variables in 1,517 inner-city youth. Obviously, even this large-scale study is limited in scope, and technically the results cannot be generalized beyond inner-city Pittsburgh youth. Nevertheless, the outcome data are interesting and lend insight into risk factors that might contribute to homicidal violence in other populations.
Results from the study indicated that violent offenders scored significantly higher than nonviolent offenders on 49 of 63 risk factors across domains associated with child, family, school, and demographic risk factors. The range and nature of these predictors were daunting. The authors reported:

. . . predictors included factors evident early in life, such as the mother’s cigarette or alcohol use during pregnancy, onset of delinquency prior to 10 years of age, physical aggression, cruelty, and callous/unemotional behavior. In addition, cognitive factors, such as having low expectations of being caught, predicted violence. Poor and unstable child-rearing factors contributed to the prediction of violence, including two or more caretaker changes prior to 10 years of age, physical punishment, poor supervision, and poor communication. Undesirable or delinquent peer behavior, based either on parent report or self-report, predicted violence. Poor school performance and truancy were also among the predictors of violence. Finally, demographic factors indicative of family disadvantage (low family SES, welfare, teenage motherhood) and residence in a disadvantaged neighborhood also predicted violence. Among the proximal correlates associated with violence were weapon carrying, weapon use, gang membership, drug selling, and persistent drug use. (p. 1084)

Homicidal violence was best predicted by a subset of general violence predictor variables. Specifically, homicide was predicted by “the presence or absence of nine significant risk factors:

In particular, boys who had at least four of these nine risk factors were 14 times more likely to have a future homicide conviction than violent offenders with a risk score less than four.

Violence and schizophrenia. In and of itself, a diagnosis of schizophrenia doesn’t confer increased violence risk. Instead, research indicates there are specific symptoms—when seen among individuals diagnosed with schizophrenia—associated with increased risk. These symptoms include severe manifestations of:

Hallucinations

Delusions

Excitement

Thinking disturbances. (Fresán, Apiquian, & Nicolini, 2006)

This research suggests that clinicians should be especially concerned about violence when clients diagnosed with schizophrenia have acute increases in the intensity and frequency of their psychotic symptoms.

Today I did an internet interview with Dr. Carlos Vazquez on his “Circle of Insight” show on IHeart Radio. A few minutes after we finished, I got an email from Dr. Carlos indicating it was posted and ready to hear. Wow. Technology is amazing and it’s especially amazing when it works.

Here’s the link to the interview. Check it out if you like. Or ignore it if you prefer.

In 2013, for the first time in the history of counseling and psychotherapy textbook writing (at least our history), Rita and I included a section heading titled “Straight Talk about Cleavage” in the 5th edition of Clinical Interviewing. This section was inspired by comments posted on the Counselor Education and Supervision Listserv (aka CESNET). Now, we’re working on the revision for the 6th edition (affectionately referred to as CI6). For CI6 we solicited reactions from students, professional counselors, and professional psychologists. Not surprisingly, we received some fun, stimulating, and challenging responses.

For your reading pleasure, here’s the first draft of the revised section on cleavage. You’ll notice that it begins with a section on “Self-Presentation.” That’s because the cleavage and related content is a subsection of the self-presentation section.

This is a draft . . . and so please feel free to message me (or post) your comments and reactions. Thanks for reading.

Self-Presentation

You are your own primary instrument for a successful interview. Your appearance and the manner in which you present yourself to clients are important components of professional clinical interviewing.

Grooming and Attire
Choosing the right professional clothing can be difficult. Some students ignore the issue; others obsess about selecting just the right outfit. The question of how to dress may reflect a larger developmental issue: How seriously do you take yourself as a professional? Is it time to take off the ripped jeans, remove the nose ring, cover the tattoo, or lose the spike heels? Is it time to don the dreaded three-piece suit or carefully pressed skirt and come out to do battle with mature reality, as your parents may have suggested? Don’t worry. We recognize the preceding sentences are probably pushing your fashion-freedom buttons. We’re not really interested in telling you how you should dress or adorn your body. Our point is self-awareness. If you’re working in rural Texas your tattoo and nose ring will have a different effect than if you’re an intern in urban Chicago. Even if you ignore your physical self-presentation, your clients—and your supervisor—probably won’t.

We knew a student whose distinctive style included closely cropped, multicolored hair; large earrings; and an odd assortment of scarves, vests, sweaters, runner’s tights, and sandals. Imagine his effect on, say, a middle-aged dairy farmer referred to the clinic for depression, or a mother-son dyad having trouble with discipline, or the local mayor and his wife. No matter what effect you imagined, the point is that there’s likely to be an effect. Clothing, body art, and jewelry are not neutral; they’re intended to communicate, and they do (Human & Biesanz, 2012). An unusual fashion statement can be overcome, but it may use up time and energy better devoted to other issues (see Putting It in Practice 2.3). As a therapist your goals is to present yourself in a way that creates positive first impressions. This includes dress and grooming that foster rapport, trust, and credibility.

In one research study (albeit dated), Hubble and Gelso (1978) reported that clients experienced less anxiety and more positive feelings toward psychotherapists who were dressed in a manner that was slightly more formal than the client’s usual attire. The take home message from this research, along with common sense, is that it’s better to err slightly on the conservative side, at least until you’re certain that dressing more casually won’t have an adverse effect on your particular client population. As a professional colleague of ours tells her students, “A client should not walk away from your session thinking too much about what you wore” (S. Patrick, personal communication, June 27, 2015).

Straight Talk about Cleavage
Although we don’t have solid scientific data upon which to base this statement, our best guess is that most people on the planet don’t engage in open conversations about cleavage. Our goal in this section is to break that norm and to encourage you to break it along with us. To start, we should confess that the whole idea of us bringing up this topic (in writing or in person) makes us feel terribly old. But we hope this choice might reflect the wisdom and perspective that comes with aging.

In recent years we’ve noticed a greater tendency for female counseling and psychology students (especially younger females) to dress in ways that might be viewed as provocative. This includes, but is not limited to, low necklines that show considerable cleavage. Among other issues, cleavage and clothing were discussed in a series of postings on the Counselor Education and Supervision (CES) listserv in 2012. The CES discussion inspired many of the following statements that follow. Please read these bulleted statements and consider discussing them as an educational activity.

• Female (and male) students have the right to express themselves via how they dress and should be able to dress any way they want.
• Commenting on how women dress and making specific recommendations may be viewed as sexist.
• Agencies and institutions have some rights to establish dress codes regarding how their paid employees and volunteers dress.
• Despite egalitarian and feminist efforts to free women from the shackles of a patriarchal society, how women dress is still interpreted as having socially constructed messages that often, but not always, pertain to sex and sexuality.
• Although efforts to change socially constructed ideas about women dressing “sexy” can include activities like campus “slut-walks,” a counseling or psychotherapy session is probably not the venue for initiating a discourse on social and feminist change.
• For better or worse, most middle-school males and middle-aged men (and many “populations” in between) are likely to be distracted—and their ability to profit from a counseling experience may be compromised—if they have a close up view of their therapist’s breasts.
• At the very least, we think excessive cleavage (please don’t ask us to define this) is less likely to contribute to positive therapy outcomes and more likely to stimulate sexual fantasies—which we believe is probably contrary to the goals of most therapists.
• It may be useful to have young women watch themselves on video from the viewpoint of a client (of any sex or gender) and then discuss how to manage sexual attraction that might occur during therapy.

We don’t have perfect answers to the question of cleavage during a clinical interview. Guidelines depend, in part, on interview setting and specific client populations. At the very least, we recommend you think about this dimension of professional attire and hope you’ll openly discuss cleavage and related issues with fellow students, colleagues, and supervisors.

Minding the Body for Males
It’s inappropriate to stop our discussion about sexuality and sexual perceptions without addressing the other end of the sexuality and gender continuum. To start, we should emphasize that, to a large extent, our cautions about cleavage aren’t really about breasts; instead, these are comments about cultural messages pertaining to sex and sexuality and how clients are likely to perceive and react to seeing too much of certain portions of their therapist’s skin. Back in Freud’s day and setting, viewing women’s ankles was reportedly rather titillating. This observation begs the question: “Is it possible for individuals who identify as being on the male end of the sexual identity continuum to dress in ways that might be described as titillating?” When we tried to experiment with this in a group counseling class, mostly the feedback was that the males were being “gross” and “disgusting.”

Despite the fact that our students reacted negatively to the idea of males exposing their skin, we should note that throughout the history of time, therapists who engaged in inappropriate, unethical, and illegal sexual behavior with clients have been disproportionately male. This leads us to conclude that our cautions about females showing cleavage is at the least ironic and at most sexist. Consistent with feminist theory, when men sexualize a woman’s body, it shouldn’t be viewed as the woman’s fault.

These issues are obviously laden with cultural stereotypes, norms, and expectations. In an effort to balance our coverage (no pun intended) of this topic, we went online and asked professionals and colleagues to give us feedback about the “Straight Talk about Cleavage” section. A summary of this feedback is included below.

Feedback on CleavageA warning to male therapists: Male therapists need to watch their own flirtatious behavior. They might consult with a female therapist friend to check out anything that might be questionable. I know, most males don’t have cleavage issues, but they sometimes do make provocative comments, such as, “You know, you should take that lovely sexuality of yours and use it to your advantage.” I’m not making this up. Also, they might want to rein in, “You are so pretty. I’ll bet this gets the guys going.” I’m not making this up either. (J. Hocker, personal communication, June 27, 2015).

Extending the conversation to male therapists: I do think part of the unfairness in professional attire for women vs. men is that men’s work wear is simply “easier.” But a woman doesn’t have to dress like a man in order to be taken seriously as a professional. Curiously, I do find that the conversation regarding appearance needs to take place with men; for example, male students who want to wear flip flops, large jewelry, or “muscle” shirts. We also talk about whether or not to wear things that reveal tattoos, hair styles, and so on – so I think men are now as much a part of the conversation as women (S. Patrick, personal communication, June 27, 2015)

A Message from a Licensed School Counselor: I know professionals in counseling and teaching who exhibit poor hygiene, dress, and might toss some cleavage out from time to time. Students do notice, and it’s not cool. In my profession I want students to see me as casual, clean, and someone they’re drawn to for a good ear and safe space. I don’t want them to see cleavage ever. It’s a distraction. Cleavage is sexy and draws attention no matter what. I’m not drawn to women sexually but I’m super distracted by cleav! I can’t imagine how a person attracted to females would react! I find that when I’m not at work there are dates and social functions available that allow me to find my sexy self, but that self doesn’t fit into the school counseling profession. Yes, women should be able to wear what they want, but the reality is if you sport cleav you’ll receive notice by everyone and there’s a time and place to celebrate our cleav; work may not be the place. (M. Robbins, personal communication, June 30, 2015)

The Man’s “Package”: I noticed there’s no mention of a man’s “package” or the open seating posture many men use that gives quite a clear view of any crotch bulging that may be had. I think this deserves to be discussed as well, and not just as an afterthought – it is at least as important as cleavage to the imagination and distraction.

One thing that seems to go on in common discourse is an acceptance of the idea that men are more sexually focused than women. This is problematic on a couple fronts, I think. Although research shows some increased arousal for men from visual stimuli compared to visual stimuli for women BOTH men and women have been shown to be aroused by visual stimuli. BOTH women and men want sex for physical pleasure, not just as a relational tool. The difference is in degree to which these things are acknowledged by each sex, perhaps, but I haven’t seen compelling evidence that there’s actually a difference in the degree to which men and women can be sexually distracted by physical bodies. It’s neither then men’s nor women’s job, then, to “protect” clients from that distraction more than another (C. Yoshimura, personal communication).

Monitoring Flirtatious Behavior
Behavior standards for mental health professionals are high. This is partly true for being a professional of any type. However, mental health professional standards for dress and flirtation are higher than most other professions. If you think about the setting and process, the high standards make sense. Personal disclosures and conversations that happen during clinical interviews and other mental health-related encounters naturally involve non-sexual intimacy. It follows that deep emotional disclosures and exchanges between client and therapist might arouse feelings related to sexual intimacy in clients and/or therapists. It’s perfectly natural for non-sexual intimacy to sometimes trigger feelings of sexual intimacy . . . and so maintaining professional boundaries in this area is essential. All ethical codes that pertain to professional counselors, psychologists, and social workers prohibit sexual contact between therapist and client. The bottom line is that it’s your responsibility, as a mental health professional or student therapist, to closely monitor your attire and behavior to make certain you’re not directly or indirectly communicating flirtatiously with your clients.